Preservative free ocular compositions and methods for using the same for treating dry eye disease and other eye disorders

ABSTRACT

The present invention provides a preservative free ophthalmic formulation. In particular, the ophthalmic formulations of the invention are aqueous formulations comprising nanoemulsion of oil. The present invention also provides a method for treating an eye disorder. In one particular embodiment, the invention provides methods for treating dry eye syndrome using an preservative free formulation comprising a nanoemulsion of oil and alpha 2 adrenergic agonist, pharmaceutically acceptable salt thereof or a mixture thereof. In particular, the alpha 2 adrenergic agonist of the invention has a higher alpha 2A agonist activity compared to alpha 2B agonist activity. This invention also provides a preservative free ophthalmic composition comprising a nanoemulsion of oil, a therapeutically effective amount of an alpha 2 adrenergic agonist, a pharmaceutically acceptable salt thereof or a combination thereof as an active ingredient for treating a dry eye syndrome.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation-in-part application of U.S. patentapplication Ser. No. 15/464,290, filed Mar. 20, 2017, which is acontinuation-in-part application of U.S. patent application Ser. No.15/051,654 filed Feb. 23, 2016, now U.S. Pat. No. 9,597,328, issued Mar.21, 2017, which claims the priority benefit of U.S. ProvisionalApplication No. 62/119,857 filed Feb. 24, 2015, all of which areincorporated herein by reference in their entirety.

FIELD OF THE INVENTION

The present invention relates to a preservative free pharmaceuticalpreparation for treatment of eye disorders containing an alpha 2adrenergic agonist. The present invention also relates to processes forproducing the same and using the same for treatment of various eyedisorders including dry eye and Meibomian gland dysfunction. Inparticular, the alpha 2 adrenergic agonist of the invention has a higheralpha 2A agonist activity compared to alpha 2B agonist activity.

BACKGROUND OF THE INVENTION

Most, if not all, conventional ocular formulations for treatment ofvarious eye disorders contain one or more preservatives in order toprolong-shelf life as well as to prevent possible microorganismcontamination. Unfortunately, it has been found recently thatpreservatives themselves cause undesired side-effects. See, for example,Alberto Aguayo Bonniard et al. in “Ocular surface toxicity from glaucomatopical medications and associated preservatives such as benzalkoniumchloride (BAK),” Expert Opin Drug Metab Toxicol., 2016 Jul. 18:1-11 (the“Bonniard et al. Reference”). As stated in the Bonniard et al.Reference, use of ocular formulations having a preservative “ . . . arecounterbalanced by the adverse effects of corneal and conjunctivaltoxicity.”

Therefore, there is a need for ocular formulations that are free ofpreservatives.

SUMMARY OF THE INVENTION

The present invention provides an ocular composition that is free of anypreservatives and methods for using the same. In some embodiments, theocular composition of the invention comprises a nanoemulsionformulation. Without being bound by any theory, it has been found thatthe presence of nanoemulsion significantly reduces the need for anypreservatives.

Still in other embodiments, the ocular formulation of the inventionincludes an α-2 adrenergic agonist can be used to treat dry eyesyndrome. Conventional methods of treating a dry eye syndrome typicallyuse an oil or hyaluronic acid. These solutions only relieve symptoms ofdry eye syndrome but do not treat the underlying cause. Furthermore,because conventional ocular formulations for treating a dry eye syndromeinclude preservatives, they are more prone to side-effects such ascorneal and/or conjunctival toxicity.

In contrast, the active ingredient in treating dry eye syndrome usingthe method of the invention involves administering a therapeuticallyeffective amount of an alpha 2 adrenergic agonist, a pharmaceuticallyacceptable salt thereof or a combination thereof. The formulation alsoincludes nanoemulsion of oil. In some embodiments, the nanoemulsion canalso include alpha 2 adrenergic agonist, while in other embodiments, themajority of alpha 2 adrenergic agonist is within the aqueous layeritself. In one particular embodiment, at least about 1%, typically atleast about 5%, often at least about 10%, more often at least about 25%,still more often at least about 50%, and most often more than 50% of theactive ingredient (e.g., alpha 2 adrenergic agonist) is present innanoemulstion. Still in another embodiment, at least about 1%, typicallyat least about 5%, often at least about 10%, more often at least about25%, still more often at least about 50%, and most often more than 50%of the active ingredient (e.g., alpha 2 adrenergic agonist) is presentin the aqueous phase of the nanoemulsion formulation. As used herein,the term “active ingredient” when reference to treating dry eye syndromerefers to a compound that is responsible for treating a dry eyesyndrome. A wide variety of ophthalmic solutions (i.e., ocularformations) contain an alpha 2 adrenergic agonist. However, as statedherein, they contain one or more preservatives which is absent informulations of the present invention.

In some embodiments, the ophthalmic solution of the invention fortreating a dry eye syndrome consists essentially of an alpha 2adrenergic agonist as the active ingredient and optionally one or moreof the following components a pharmaceutically acceptable excipient; andwater. Still in other embodiments, the alpha 2 adrenergic agonist or apharmaceutically acceptable salt thereof used in treating a dry eyesyndrome has a higher alpha 2A agonist activity compared to alpha 2Bagonist activity.

DETAILED DESCRIPTION OF THE INVENTION

The two major classes of dry eye (or dry eye syndrome) are aqueoustear-deficient dry eye (ADDE) and evaporative dry eye (EDE). There arealso cases of mixed mechanism dry eye (i.e., both ADDE and EDE). ADDE isdue to failure of lacrimal tear secretion and this class can be furthersubdivided into Sjogren syndrome dry eye (where the lacrimal andsalivary glands are targeted by an autoimmune process, e.g., rheumatoidarthritis) and non-Sjogren's syndrome dry eye (lacrimal dysfunction, butthe systemic autoimmune features of Sjogren's syndrome are excluded,e.g., age-related dry eye). EDE is due to excessive water loss from theexposed ocular surface in the presence of normal lacrimal secretoryfunction. Its causes can be extrinsic (e.g., ocular surface disorder dueto some extrinsic exposure, contact lens wear or vitamin A deficiency)or intrinsic (e.g., Meibomian gland dysfunction and disorders of eyelidaperture).

Meibomian glands, sebaceous glands in the tarsus of the eyelids, consistof multiple acini emptying into a central duct that opens at the surfaceof the lid margin just anterior to the mucocutaneous junction. Theeyelid margin is for most part lined by the skin. The cornifiedskin-type epithelium of eyelid margin abruptly changes tonon-keratinized epithelium posterior to the opening of the meibomiangland ducts (PMID: 21413985). Blood vessels and nerves are located indeeper layers of skin and in the substantia propria.

Meibomian glands secrete a mixture of lipids and other components thatform the outer layer of the preocular tear film. This lipid layerfunctions to decrease tear film evaporation. Meibomian gland dysfunction(MGD) leads to evaporative dry eye disease. Typical slit lampbiomicroscope findings in MGD include: lid margin telangiectasia,anastomosis of vessels on mucocutaneous junction, poor expression ofMeibomian secretions by digital pressure, turbid meibum with increasedpaste like consistency, dropout of Meibomian gland acini andobliteration of Meibomian duct orificies. One of the most wellrecognized clinic finding in MGD is the presence of numeroustelangiectatic blood vessels coursing across the eyelid margin. MGD alsoaccompanies tear deficient dry eye disease, like ocularGraft-versus-host-disease (oGVHD) and Sjogren's dry eye syndrome.Treatment of Meibomian gland dysfunction by topical application oftherapeutic agents would therefore provide an attractive treatment ofevaporative dry eye disease and mixed mechanism dry eye disease.

Dry eye symptoms have traditionally been managed with eyelid hygiene,topical antibiotics (erythromycin or bacitracin ointments), oraltetracyclines (tetracycline, doxycycline, or minocycline),anti-inflammatory compounds (cyclosporine) and corticosteroids which areoften time consuming, frustrating, and frequently ineffective orvariably effective treatments. Further, ointments, creams etc., may notdisrupt the barriers including mucosal, mucocutaneous, and stratumcorneal layers (superficial cornified layers of skin) and may not reachthe blood vessels and nerves that are present deeper in the eyelidtissue. Thus, there exists an ongoing need for methods and compositionsfor enhancing the bioavailability of drugs in the vicinity of the targettissues (blood vessels and nerves). Furthermore, cyclosporine-A(Restasis®) is the only approved treatment for dry eye syndrome in U.S.but it is only indicated for part of the dry eye patients whose tearproduction is presumed to be suppressed due to ocular inflammationassociated with keratoconjunctivitis sicca. Despite the high incidenceof dry eye and other eye disorders, there is currently no consistentlyeffective treatment for these conditions and it still remains atherapeutic challenge. More significantly, majority of the conventionalophthalmic solutions include preservatives that can further exacerbatethe dry eye syndrome or cause other undesired side-effects including,but not limited to, corneal and conjunctival toxicity.

Some aspects of the invention provide new therapeutic modalities totreat eye disorders including MGD and dry eye syndrome without the needfor having a preservative. As used herein, the term “preservative free”means the amount or preservative is not intentionally added to theformulation. Alternatively, while a minute amount of preservative can bepresent, the total amount of the preservative does not significantlyaffected. Still alternatively, any amount of preservative that may bepresent in compositions of the invention is less than 50%, typicallyless than 75%, often less than 80%, still more often less than 90%, andmost often less than 95% compared to that present in conventionalformulations. In some embodiments, “preservative free” means the amountof preservative present is less than 0.05% by weight, typically lessthan 0.01% by weight, more often less than 0.001% by weight, and mostoften is absent.

In some embodiments, the nanoemulsion size of composition of theinvention is about 250 nm or less, typically about 220 nm or less, andoften about 200 nm or less. Such a small size nanoemulsion formulationresults in removal of any microbial organisms that may be present duringthe manufacturing process. This can be achieved, for example, byfiltering the emulsion using 22 micron sterile filtration membranesduring the production process. Once the nanoemulsion formulation ismanufactured as microbial organism free composition, the resultingproduct is stored and maintained as sterile product, for example, eitherin single use containers such as blow fill seal (BFS) containers orpreservative free multidose containers such as Aptar or Nemeracontainer/closure.

One particular aspect of the invention provides preservative freeophthalmic formulations containing an alpha 2 adrenergic agonist for thetreatment of eye disorders including Meibomian gland dysfunction (MGD)and dry eye syndrome. In some embodiments, the ophthalmic formulationsinclude nanoemulsion of oil. In particular, the active compound fortreating a dry eye syndrome consists essentially of alpha 2 adrenergicagonist. In some embodiments, the active compound consists of alpha 2adrenergic agonist having a higher alpha 2A agonist activity compared toalpha 2B agonist activity.

Representative alpha 2 adrenergic receptor agonist include 4-NEMD,7-Me-marsanidine, Agmatine, Apraclonidine, Brimonidine, Cannabigerol,Clonidine, Detomidine, Dexmedetomidine, Fadolmidine, Guanabenz,Guanfacine, Lofexidine, Marsanidine, Medetomidine, Methamphetamine,Mivazerol, Rilmenidine, Romifidine, Talipexole, Tizanidine, Tolonidine,Xylazine, Xylometazoline, and the like including pharmaceuticallyacceptable salts thereof. In one particular embodiment, the alpha 2adrenergic receptor agonist is brimonidine(5-Bromo-N-(4,5-dihydro-1H-imidazol-2-yl) quinoxalin-6-amine), apharmaceutically acceptable salt thereof or a combination thereof.

In some embodiments, the alpha 2 adrenergic agonist used in ophthalmiccompositions of the invention has a higher alpha 2A agonist activitycompared to alpha 2B agonist activity. In some instances, the alpha 2Aagonist activity of the alpha 2 adrenergic agonist is at least about 10%greater, typically at least about 20% greater and often at least about30% greater than its alpha 2B agonist activity. As used herein, the term“about” when referring to a numeric value means±20%, typically ±10%,often ±5% and most often ±2% of the numeric value.

In other embodiments, the alpha 2 adrenergic receptor agonist may beapplied alone or in combination with non-alpha 2 adrenergic receptoragonist agents such as corticosteroids (e.g., methylprednisolone,hydrocortisone, betamethasone and dexamethasone), CRGP receptorantigonists or anti-CGRP receptor monoclonal antibodies. Othercombinations can include inhibitors of adrenomedullin, serotonin,cathelicidin and neuropeptides such as NPY.

In an embodiment, the composition comprises about 0.001 to about 5 mg/mlbrimonidine in aqueous medium. In another embodiment, the compositioncomprises about 0.15 mg/ml brimonidine in aqueous solution. A particularcomposition comprises about 0.15 mg/ml brimonidine and about 0.5 mg/mlmethylprednisone in aqueous solution.

Optionally, an amount of a penetrating agent may also be included in anyof the compositions of the invention to aid penetration of the activecomponent into and across the skin or eyelid skin such as for example,aliphatic alcohol, fatty acid and a salt thereof, fatty acid ester,polyalcohol alkyl ether, polyoxyethylene alkyl ether, glyceride,polyalcohol medium chain fatty acid ester, polyoxyethylene sorbitanfatty acid ester, alkyl lactate ester, terpenes and organic amine. Morespecifically, the percutaeous penetrating agent may be ethanol,glycerol, diethylene glycol, propylene glycol, polyethylene glycol andhigher aliphatic alcohols (saturated or unsaturated higher aliphaticalcohol having 12 to 22 carbon atoms such as oleyl alcohol, laurylalcohol and stearyl alcohol), capric acid, myristic acid, palmitic acid,lauric acid, stearic acid, isostearic acid, oleic acid, linoleic acidand linolenic acid, and a salt thereof (for example, sodium salt,potassium salt, magnesium salt, calcium salt and aluminium salt),include an ester of a fatty acid such as myristic acid, palmitic acid,lauric acid, stearic acid, isostearic acid, oleic acid, linoleic acid,linolenic acid, propionic acid, butyric acid, isobutyric acid, valericacid, pivalic acid, caproic acid, heptanoic acid, malonic acid, succinicacid, glutaric acid, adipic acid, pimelic acid, crotonic acid, sorbicacid, maleic acid, fumaric acid and sebacic acid with a lower aliphaticalcohol such as methanol, ethanol, propanol, isopropanol, butanol,pentanol, hexanol, heptanol and octanol, isopropyl myristate, isopropylpalmitate, diisopropyl adipate and diethyl sebacate, an ether of apolyalcohol such as glycerol, ethylene glycol, propylene glycol,1,3-butylene glycol, diglycerol, polyglycerol, diethylene glycol,polyethylene glycol, dipropylene glycol, polypropylene glycol, sorbitan,sorbitol, methyl glucoside, oligosaccharide and reduced oligosaccharidewith alkyl alcohol, polyoxyethylene lauryl ether, polyoxyethylene cetylether, polyoxyethylene stearyl ether and polyoxyethylene oleyl ether,glycerol ester of fatty acid having 6 to 18 carbon atoms (e.g,monoglyceride, diglyceride, triglyceride and a mixture thereof),glyceryl monolaurate, glyceryl monomyristate, glyceryl monostearate,glyceryl monooleate, glyceryl dilaurate, glyceryl dimyristate, glyceryldistearate, glyceryl trilaurate, glyceryl trimyristate and glyceryltristearate, ethylene glycol monocaprylate, propylene glycolmonocaprylate, glycerin monocaprylate, mono 2-ethylene glycolethylhexanoate, mono 2-propylene glycol ethylhexanoate,di(2-propylene)glycol ethylhexanoate, propylene glycol, dicaprylate,polyoxyethylene sorbitan monolaurate, polyoxyethylene sorbitanmonostearate and polyoxyethylene sorbitan monooleate, methyl lactate,ethyl lactate, methyl 2-methoxy propionate and ethyl2-methoxypropionate, monoethanolamine, triethanolamine, creatinine andmeglumine. In certain embodiments of the invention one or more of fattyacid ester, polyoxyethylene, isopropyl myristate and polyoxyethyleneoleyl ether is included in the composition. In other embodiments of theinvention a penetrating agent or combination of agents such as1-acyl-azacycloheptan-2-one (azone), 1-acyl-glucoside,1-acyl-poly(oxyethylene), 1-acyl-saccharide, 2-(n-acyl)-cyclohexanone,1-alkanol, 1-alkanoic acid, 2-(n-acyl)-1,3-doxolane (SEP A),1,2,3-triacylglyceride, 1-alkylacetate, alkyl-sulfate, dialkyl sulfate,and phenyl-alkyl-amine may be added to the composition.

Also optionally, an amount of a hydrating agent such as hyaluronic acid,saline solution, and/or polyvinylpyrrolidone, may be included in any ofthe compositions of the invention. Ophthalmic compositions of theinvention that are intended to penetrate the barriers generally,although not necessarily, include an amount of a hydrating agent tofacilitate penetration of the therapeutic agent through the cell orjunctions of the barriers including mucosal, mucocutaneous, and stratumcorneum layers.

When included in the compositions of the invention, penetrating agentsare generally in the amount of from 0.01% to 50% by weight of thecomposition and in some embodiments from 0.1% to about 40% by weight ofthe composition, 1% to about 35% and in other embodiments from about 5%to about 30% by weight of the composition and the amount of hydratingagent is in the range of from 0.001% to 30% by weight of thecomposition, in other embodiments from 0.01 to 25% by weight of thecomposition, in still other embodiments, from 0.1% to 10% by weight ofthe composition. In one particular embodiment, from 0.1 to 5% by weightof the composition.

In addition to the components discussed above, any component generallyused for manufacturing medicine in the desired form can be added to thepresent compositions of the invention, if desired. Examples of suchcomponents include a base matrix for adhesive preparations, an ointmentbase, gel base, solvent, oil, crosslinking agent, surfactant, gum,resin, pH adjuster, stabilizer, antioxidant, ultraviolet absorbent andwetting agent. A percutaneous absorption enhancer can be added, ifdesired.

Surfactant may be included in the compositions of the invention tofacilitate dissolution of formulation components and/or absorption,including anionic surfactant, cationic surfactant, nonionic surfactantand amphoteric surfactant. Useful surfactants include fatty acid salt,alkyl sulfate, polyoxyethylene alkyl sulfate, alkyl sulfo carboxylate,alkyl ether carboxylate, amine salt, quanternary ammonium salt,polysorbate 80, poloxamers, polyoxyethylene hydrogenated castor oil,polyoxyethylene fatty acid ester, polyoxyethylene alkyl ether,polyoxyethylene sorbitan fatty acid ester, alkyl betaine,dimethylalkylglycine and lecithin.

If desired, gum and/or resin may be included in the compositions of theinvention, including for example, sodium polyacrylate, cellulose ether,calcium alginate, carboxyvinyl polymer, ethylene-acrylic acid copolymer,vinyl pyrrolidone polymer, vinyl alcohol-vinyl pyrrolidone copolymer,nitrogen-substituted acrylamide polymer, polyacrylamide, cationicpolymer such as cationic guar gum, dimethylacrylic ammonium polymer,acrylic acid-methacrylic acid copolymer, polyoxyethylene-polypropylenecopolymer, polyvinyl alcohol, pullulan, agar, gelatine, chitosan,polysaccharide from tamarindo seed, xanthan gum, carageenan,high-methoxyl pectin, low-methoxyl pectin, guar gum, acacia gum,microcrystalline cellulose, arabinogalactan, karaya gum, tragacanth gum,alginate, albumin, casein, curdlan, gellan gum, dextran, cellulose,polyethyleneimine, high polymerized polyethylene glycol, cationicsilicone polymer, synthetic latex, acrylic silicone,trimethylsiloxysilicate and fluorinated silicone resin.

A pH adjuster may be used in the compositions to adjust pH of thecomposition to a desired range, such as pH 4-10, or pH 5-8, for exampleor any range that maximizes the penetration through the skin of theparticular drug in the composition. pH adjustment can be achievedthrough use of various chemicals such as hydrochloric acid, citric acid,sodium citrate, acetic acid, sodium acetate, tris, tris base, sodiumhydroxide, ammonium acetate, succinic acid, tartaric acid, L-sodiumtartrate, sodium hydrate, potassium hydrate, sodium carbonate, sodiumhydrogencarbonate, lactic acid, calcium lactate, sodium lactate, sodiumfumarate, sodium propionate, boric acid, ammonium borate, maleic acid,phosphoric acid, sodium hydrogenphosphate, dl-malic acid, adipic acid,triethanolamine, diisopropanolamine, meglumine, monoethanolamine,sulfuric acid and aluminum potassium sulfate and the like.

Stabilizers may optionally be included in the compositions of theinvention. Useful stabilizers include for example sodium bisulfite,sodium sulfite, sodium pyrosulfite, sodium formaldehyde sulfoxylate,L-ascorbic acid, erythorbic acid, L-cysteine, thioglycerol, butylatedhydroxyanisole (BHA), butylated hydroxytoluene (BHT), propyl gallate,ascorbyl palmitate, dl-α-tocopherol, nordihydroguaiaretic acid,1-hydroxyethylidene-1,1-diphosphonic acid, disodium edetate, tetrasodiumedetate dehydrate, sodium citrate, sodium polyphosphate, sodiummetaphosphate, gluconic acid, phosphoric acid, citric acid, ascorbicacid and/or succinic acid.

Other optional components of the compositions include wetting agentssuch as glycerol, polyethylene glycol, sorbitol, mannitoltol,propylene-glycol, 1,3-butanediol and hydrogenated maltose syrup;antioxidants such as sodium bisulfite, sodium sulfite, sodiumpyrosulfite, sodium formaldehyde sulfoxylate, L-ascorbic acid,erythorbic acid, L-cysteine, thioglycerol, butylated hydroxyanisole(BHA), butylated hydroxytoluene (BHT), propyl gallate, ascorbyl,palmitate, dl-.alpha.-tocopherol and nordihydroguaiaretic acid;ultraviolet absorbent such as octyl methoxycinnamate, glycerylmonooctanoate di-para-methoxy cinnamate,2-hydroxy-4-methoxybenzophenone, para-aminobenzoic acid,para-aminobenzoic acid glycerol ester, N,N-dipropoxy-para-aminobenzoicacid ethyl ester, N,N-diethoxy-para-aminobenzoic acid ethyl ester,N,N-dimethyl-para-aminobenzoic aid ethyl ester,N,N-dimethyl-para-aminobenzoic acid butyl ester, homomethylN-acetylanthranilate, amyl salicylate, menthyl salicylate, homomethylsalicylate, octyl salicylate, phenyl salicylate, benzyl salicylate andp-isopropyl phenyl salicylate.

The formulations are not limited in form and may include for exampleliposomes and other vesicles, such as transfersomes, which includesurface active agents and are particularly useful for the transdermaldelivery of large molecules such as peptide and proteins; and thosomes,which are liposomes that contain ethanol, which functions as apermeation enhancer.

In an embodiment, the liquid composition is prepared using aphysiological saline solution as a major vehicle. The pH of suchsolutions should preferably be maintained between 4.5 and 8.0 with anappropriate buffer system, a neutral pH being preferred but notessential. The formulations may also contain conventional,pharmaceutically acceptable stabilizers and surfactants. A preferredsurfactant is, for example, Tween 80. Likewise, various preferredvehicles may be used in the ophthalmic preparations of the presentinvention. These vehicles include, but are not limited to, polyvinylalcohol, povidone, hydroxypropyl methyl cellulose, poloxamers,carboxymethyl cellulose, hydroxyethyl cellulose cyclodextrin andpurified water (water).

Tonicity adjustors may be added as needed or convenient. They include,but are not limited to, salts, particularly sodium chloride, potassiumchloride, mannitol and glycerin, or any other suitable ophthalmicallyacceptable tonicity adjustor. Various buffers and means for adjusting pHmay be used so long as the resulting preparation is ophthalmicallyacceptable. Accordingly, buffers include acetate buffers, citratebuffers, phosphate buffers and borate buffers. Acids or bases may beused to adjust the pH of these formulations as needed. In a similarvein, an ophthalmically acceptable antioxidant for use in the presentinvention includes, but is not limited to, sodium metabisulfite, sodiumthiosulfate, acetylcysteine, butylated hydroxyanisole and butylatedhydroxytoluene. Other excipient components which may be included in theophthalmic preparations are chelating agents and antibiotics. Thepreferred chelating agent is edetate disodium, although other chelatingagents may also be used in place of or in conjunction with it.Non-limiting examples of antibiotics useful in the present inventioninclude trimethoprim sulfate/polymyxin B sulfate, gatifloxacin,moxifloxacin hydrochloride, tobramycin, teicoplanin, vancomycin,azithromycin, clarithromycin, amoxicillin, penicillin, ampicillin,carbenicillin, ciprofloxacin, levofloxacin, amikacin, gentamicin,kanamycin, neomycin and streptomycin,

The ingredients are usually used in the following amounts: IngredientAmount (% w/v) active ingredient about 0.001-5; vehicle 0-40; tonicityadjustor 0-10; buffer 0.01-10; pH adjustor q.s. pH 4.5-8.0; antioxidantas needed; surfactant as needed; and purified water as needed to make100%.

Thus, in an aspect, the present invention generally relates toophthalmological compositions or formulations having an alpha 2adrenergic agonist and various components exemplified above (non-alpha 2adrenergic agonist active agents e.g., corticosteriods and other activeagents, a penetration enhancer, a hydrating agent, a surfactant, a gum,a resin, a pH adjuster, a stabilizer, a wetting agent and/or a tonicityadjustor) generally used for manufacturing a medicine, for example, inthe form of a liquid, an emulsion, or a suspension, an ointment, a gel,an aerosol, a mist, a polymer, a film or a paste. The ophthalmologicalformulations containing water include dosage forms such as ophthalmicoil-in-water emulsions, eye hydrogels, eye drop solutions, eyebaths, eyelotions, eye inserts, eye ointments and eye sprays and preparations forintraocular application. These formulations of the present inventioncontain about 0.01 to about 5 mg/ml (about 0.001% to about 0.5%)preferably about 0.2% or less (e.g., 0.05-0.2% preferably 0.07-0.15%) ofbrimonidine or a salt thereof (e.g., brimonidine tartrate). In someembodiments, the total amount of brimonidine, a salt thereof, or acombination thereof present in formulations of the invention ranges from0.1% to 0.25%, typically 0.14% to 0.2%, often 0.15% to 0.2%, and stillmore often about 0.18%. The ingredient amounts are presented in units ofeither % weight/volume (% w/v) or weight/weight (% w/w).

To provide the ophthalmic formulations with a pH substantiallycorresponding to the pH of the fluids of the eye or at an acceptablephysiological pH, as described above, the pH of the ophthalmicformulation can be adjusted, if required, by addition of an acid or abase. In this regard, the ophthalmic formulations have a pH value in therange of about 5.5 to about 8, preferably about 6.0 to about 7.5 or sothat the pH of the ophthalmic formulation substantially corresponds tothe pH value of the fluids in the human eye. To buffer the ophthalmicformulation at the desired pH, an effective amount of at least onebuffer (also referred to herein as buffer component) can be incorporatedinto the formulation. The effective amount of buffer component employedto buffer or maintain or stabilize the formulation at the desired pH canvary and depends to a large degree on the particular buffer componentemployed, as well as the chemical composition of the ophthalmicformulation. When it is determined that the buffered ophthalmicformulation does not have the desired pH value, the pH of the aqueousbuffered ophthalmic formulation can be adjusted by the addition of acidsor bases in quantity sufficient to achieve the desired pH. An example ofan acid which can be used to adjust the pH of the aqueous bufferedophthalmic formulation is 1N hydrochloric acid and an example of a basewhich can be used to adjust the pH of the aqueous buffered ophthalmicformulation is 1N sodium hydroxide. In an embodiment of the invention,however, the ophthalmic formulations of the present invention contain acombination of dibasic and monobasic phosphate or boric acid and sodiumborate—as buffering agents. The formulations contain an amount of boricacid and sodium borate sufficient to buffer the formulation in a pHrange of 7.5-8.0 or dibasic and monobasic phosphate sufficient to bufferthe formulation in a pH range of 7.5-8.0. In addition, boric acid andits ophthalmically acceptable acid addition salts, as well asborate-polyol complexes, known in the art.

The ophthalmic formulations can have an osmolality or tonicity of atleast about 200 mOsmol/kg, preferably in the range of about 200 to about350 or about 400 mOsmol/kg. In a preferred embodiment, the osmolality ortonicity of the formulation substantially corresponds to the tonicity ofthe fluids of the eye, in particular the human eye. In one embodiment,the tonicity adjustor is selected from inorganic salts such as sodiumchloride, potassium chloride, calcium chloride and magnesium chlorideand mixtures thereof.

Generally speaking, when ophthalmological formulations are appliedtopically in the form of, for example, drops or ointment to the cornea,the dosage form rapidly disperses into the tear film and flows into thetear drainage system, thereby reducing ocular bioavailability of theactive ingredient. In practicing the present invention, one skilled inthe art would be able to address such issues by adjusting the dosingregimens (e.g., once a day, two times per day or four times per day,etc.) and/or by the use of drug delivery systems such as soft contactlenses, collagen shields, scleral lenses, etc., as a means of increasingbioavailability of alpha 2 adrenergic agonist in the precorneal area andocular surface, lid margins, cornea, and to the anterior chamber of theeye, as necessary to treat MGD or dry eye. Such delivery systems andtheir manufacture are known in the art.

The formulations of the present invention can be packaged in variouspackage forms known in the field of topical ophthalmics. In oneembodiment, the formulation is packaged in sterile, preservative-freesingle-use packs or vials or containers (i.e., the unit dose vials).Each vial, for example as small as a 0.9 mL, may be made of low densitypolyethylene so as to contain a small quantity of the formulation, e.g.0.4 mL fill until use. This way, where the pharmaceutical composition issterilized and contained in disposable single-dose containers fortopical use in drop form, multiple vials in the form of a set of 30vials, 60 vials and so on can be packaged in a tray with a lid, forexample, a polypropylene tray with an aluminum peelable lid. The entirecontents of each tray can be dispensed intact, and one vial or pack isused each time and immediately discarded after each use. For example,plastic ampules or vials or containers can be manufactured usingblow-fill-seal (BFS) technology. The BFS processes may involve plasticextrusion, molding, aseptic filling, and hermetic sealing in onesequential operation and those processes are known in the art.

In a preferred embodiment, the dosage form of the invention is eye dropsof oil-in-water emulsions, eye drop solutions containing the activeingredient brimonidine or a salt thereof solutions. Eye drops preferablycontain, according to the invention, aqueous or oily suspensions of theactive ingredient in pharmaceutically acceptable carriers and/orexcipients. It is preferred in this connection for the particle size ofthe active ingredient employed to be less than 0.22 μm.

An example of various components (w/w) of a topical ophthalmic liquidformulation useful for treating an eye disorder (e.g., dry eye syndromeor MGD) in a human patient is as follows: brimonidine tartrate in theamount of 0.01% to 0.5% by weight, preferably about 0.1 to 0.25%; 5 mMphosphate (combination of dibasic and monobasic), sodium citrate, trisbase buffer of pH 6.0-8.0; a tonicity agent including mannitol orglycerol of up to 5% by weight (in the range of 2-5% by weight); sodiumEDTA in the amount of about 0.02% or less by weight, a small amount ofthickening agents such as sodium carboxy methyl cellulose, HPMC orsodium hyaluronate. This formulation can be prepared by first preparingphosphate buffer with pH stabilized, for example, at pH 6 to pH 8.0(typically pH 6 to pH 7.5 and often pH 6 to pH 7) and then dissolvingbrimonidine tartrate in it by mixing thoroughly. Then, the remainingexcipients are added and mixed thoroughly into solution. Final solutionis sterile filtered using 0.22 micron filter and filled into single dosedisposable tubes using, for example, BFS or

An example of a topical ophthalmic oil-in-water emulsion with itsvarious components (w/w) useful for treating an eye disorder is asfollows: brimonidine tartrate in the amount of 0.02% to 1.0% by weight,typically about 0.1% to 0.5%; surfactant such as Polysorbate 80 at about0.02%-2% by weight or poloxamer/tyloxapol at about 0.1% and 0.25% byweight; carbomer copolymer (type A or type B) about 0.05% by weight;tonicity agent (glycerine or includes glycerine about 2.2% by weight;phosphate (combination of dibasic and monobasic) buffer of pH 7.4-8.0,preferably about 8.0 so as to make brimonidine more non-ionic beyondit's pKa of 7.8; sodium EDTA in the amount of about 0.02% or less byweight; an oil (e.g., castor oil) in the amount of about 1.25% byweight. Alternatively, the oil for the oil phase is a medium chaintriglyceride in the range from 0.5-4%, preferably at about 2%. Toprepare this formulation, all water soluble components except forbrimonidine can be added and heated (about 60-70° C.) to make water thephase with buffer. Oil phase, the oil (e.g., castor oil) is heated toabout 60-70° C. and brimonidine tartrate is dissolved or dispersed init. Coarse emulsion is formed by rapid addition of oil into water phasefollowed by high shear mixing. Final emulsion is obtained by highpressure homogenization in a suitable equipment such as microfluidizerusing several continuous cycles to obtain droplet size of less than 200nm. The final emulsion is sterilized via 0.22 micron filter.Alternatively, sterilization can also be done by autoclaving at about121° C. for 20 min. The sterilized emulsion is filled into single dosedisposable tubes by BFS technology or the like.

Another example of a topical ophthalmic oil-in-water emulsion with itsvarious components (w/w) useful for treating an eye disorder (e.g., dryeye syndrome or MGD) is as follows: it contains colloid particles withan average particle size of equal to or less than 0.2 μm and greaterthan 0.02 μm and has an oily core surrounded by an interfacial film. Thesize population distribution of the colloidal particles may bemonomodal. The emulsion contains anywhere from 0.05% to 1% (e.g.,typically about 0.1% to about 0.5%, often about 0.15% to about 0.5%)alpha 2 adrenergic receptor agonist (e.g., brimonidine or a saltthereof) in weight to the total weight (w/w) of the emulsion, 0.5 to 4%w/w (e.g., 2% w/w) medium-chain triglycerides for single dose sterilecontainers, and surfactants. The surfactants, for example, consist of amixture of tyloxapol in an amount of 0.3% w/w and poloxamer in an amountof 0.1% w/w. The ophthalmic oil-in-water emulsion can include one ormore oils selected from olive, soy, corn, mineral, cottonseed, safflowerand sesame. The emulsion does not contain substances capable ofgenerating a negative charge and/or phospholipids. The ophthalmicoil-in-water emulsion can be used for treating a dry eye syndrome orMGD.

Yet another example of a topical ophthalmic oil-in-water emulsion withits various components (w/w) useful for treating an eye disorder is asfollows: It contains an alpha 2 adrenergic receptor agonist in an amountof about 0.05%; polysorbate 80 (e.g. about 1.0% by weight);acrylate/C10-30 alkyl acrylate cross-polymer (about 0.05% by weight);water q.s.; and castor oil in an amount of about 1.25% by weight. Thealpha 2 adrenergic receptor agonist is the only active agent present inthe topical ophthalmic emulsion but contains a tonicity agent or ademulcent component (e.g., glycerine, which can be in an amount of about2.2% by weight), a buffer. The pH of this topical ophthalmic emulsionmay be in the range of about 7.4 to about 8.0. The topical ophthalmicemulsion is therapeutically effective in increasing tear production.

Yet another example of a topical ophthalmic oil-in-water emulsion withits various components (w/w) useful for treating an eye disorder is asfollows: It contains an alpha 2 adrenergic receptor agonist brimonidinetartrate in an amount of about 0.1% to about 0.5%; polysorbate 80 (e.g.about 4% by weight); glycerin about 2.2%; carbomer copolymer type B(allyl pentaerythritol crosslinked) about 0.05% or the carbomer; sodiumacetate 0.05%; boric acid about 0.1%; sodium ethylene diamine tetraacetic acid about 0.02%; sorbic acid about 0.1%; castor oil in an amountof about 5%; water q.s. to 20 ml (20 gms), preferably as part of asuitable buffer (boric acid/sodium acetate buffer can be substitutedwith mono/dibasic phosphate buffer) for this and other non-limitingexamples described herein; and sodium hydroxide (0.1 N) q.s. to make pH7.4-8.0; and water q.s. to 20 ml (20 gms). The topical ophthalmicemulsion is therapeutically effective for treating eye disorders.

Yet another example of a topical ophthalmic nanoemulsion of oil-in-waterwith its various components (w/w) useful for treating an eye disorder isas follows: an alpha 2 adrenergic receptor agonist brimonidine tartratein an amount of about 0.1 to 0.25% (typically 0.14%, 0.18% or 0.2%);polysorbate 80 (e.g., about 4% by weight or about 2% or about 1%);glycerin about 2.2% or about 2.3%; polyacrylic acid (copolymer acrylicacid and methacrylate) about 0.05% or the carbomer or Pemulen® TR-2 orcarbomer copolymer type A [allyl pentaerythritol crosslinked about 0.04to 0.07%; sodium citrate about 0.1 to 0.2%, tris about 0.03 to 0.15%;castor oil in an amount of about 1 to 2%; water q.s. to 20 ml (20 g),preferably as part of a suitable buffer for this and other non-limitingexamples described herein; and sodium hydroxide (0.1 N) q.s. to make pH6.0-8.0; and water q.s. to 20 ml (20 gms). The topical ophthalmicnanoemulsion is therapeutically effective for treating eye disorders.

Yet another example of a topical ophthalmic oil-in-water emulsion withits various components (w/w) is as follows: It contains brimonidinetartrate in an amount ranging from about 0.01% to about 0.5%, preferablyin an amount of about 0.1% to 0.5%; carbomer homopolymer type B in anamount ranging from about 0.2 to about 0.6%, preferably in an amount ofabout 0.4% or about 0.25%, and/or carbomer homopolymer type C in anamount ranging from about 0.4 to about 5% preferably in an amount ofabout 4% or about 2.5%, and/or polycarbophil in an amount ranging fromabout 0.2% to about 0.5% preferably in an amount of about 0.4% or about0.2%; glycerin in an amount ranging from about 0.5% to about 1%preferably in an amount of about 0.9%; edetate sodium in an amountranging from about 0.03% to about 0.07% preferably in an amount of about0.05%; sodium chloride in an amount of up to about 0.09%, preferably inan amount of about 0.06% or q.s. to isotonicity, or mannitol q.s. toisotonicity, or without isotonicity adjustors sodium chloride andmannitol; propylene glycol in an amount ranging from about 0.3% to about0.6% preferably in an amount of about 0.5%; water q.s., to 100 gms andsodium hydroxide or hydrochloric acid q.s., to adjust pH to 7.8. Thetopical ophthalmic emulsion is therapeutically effective for treatingeye disorders. In all cases the formulations of the invention arepreservative-free.

An example of a topical ophthalmic formulation with its variouscomponents (w/w) with a gel base useful for treating an eye disorder isas follows: The formulation contains an alpha 2 adrenergic receptoragonist and a hydrogel. The hydrogel can be hyaluronic acid,hydroxypropyl cellulose, hydroxypropylmethyl cellulose,hydroxyethylcellulose, polyvinyl pyrolidone, carboxymethylcellulosehydroxyethyl cellulose or polyvinylpyrrolidone.

These examples of topical ophthalmic compositions are intended toillustrate, but not limit, the present invention, are as describedherein.

This invention also relates to a sealed package in which are sealed oneor more pre-packaged disposable applicator sticks. The applicator stickscomprise an elongated handle portion and an absorbent applicator headportion containing a controlled amount of a composition comprising analpha 2 adrenergic agonist (representative alpha 2 adrenergic agonistshaving described elsewhere herein) and an elongated handle portion.Thus, an embodiment of the medicinal applicator sticks containing anabsorbent head portion and an elongated handle portion where acontrolled amount of a composition comprising analpha 2 adrenergicagonist is absorbed in or adhered to the head portion is provided. Theapplicator sticks are disposable. Such disposable applicator sticks arecommercially available. The disposable applicator stick(s) are removedfrom the sealed package by a clinician and used to apply atherapeutically effective amount of an alpha 2 adrenergic agonistdirectly to the margins of the eyelids of a subject in need of treatmentfor Meibomian gland dysfunction.

Compositions suitable for application using the applicator stick of theinvention include liquid compositions for absorption by the absorbenthead portion of the applicator stick or ointments adhered to theabsorbent head portion of the applicator stick; typical liquidcompositions are aqueous solutions of the alpha 2 adrenergic agonist andointments are typically suspension of the alpha 2 adrenergic agonist inmineral oil or petrolatum jelly.

With respect to the medicinal applicator aspect of the invention, theterm “controlled amount of a composition” refers to a predeterminedamount of the composition comprising the alpha 2 adrenergic agonist thatis absorbed in or adhered to the absorbent head of the applicator stick.The controlled amount can be readily determined by routineexperimentation based on the characteristics of the composition and theabsorbent head portion material(s). For example, in the case of a liquidcomposition, the predetermined amount is the amount of the liquidcomposition whereby the absorbent head portion of the applicator stickis not supersaturated but is just or almost fully saturated therewith.This avoids the problem of the liquid composition pooling in the packageupon storage or running down the stick in the event the package istilted.

The liquid absorbent applicator head portion of the applicator sticktypically comprises absorbent fibers fixed to one end of the applicatorstick. The absorbent fibers may be made of any naturally-occurring orsynthetic fibers capable of absorbing the controlled amount of theliquid composition and then releasing the liquid composition in acontrolled fashion upon contact with the subject's eyelid margin. Incertain embodiments, the absorbent fibers comprise woven or unwovencotton fibers. In other embodiments the absorbent fibers may comprise anabsorbent foam such as polyurethane foam. The absorbent fibers may beadhesively attached to the end of the stick. The sticks may bemanufactured from any material conventionally used for this purposeincluding wood, paper, plastic, and the like. In an embodiment, theapplicator sticks are commercially-available cotton-tipped swabs forapplying liquid-type materials.

Packaging systems for disposable applicator sticks are known in the art.In an embodiment, one or more applicator sticks according to theinvention may be sealed in a pouch composed of a suitable flexiblematerial (e.g. foil). Thus, an embodiment of the medicinal applicatoraspect is a combination medicinal applicator and sealed package assemblytherefor. The combination has at least one applicator having a liquidabsorbent head portion and an elongated handle portion and a sealedpackage enclosing said at least one applicator.

Generally, in this aspect, a controlled amount of a compositioncontaining an alpha 2 adrenergic agonist (e.g., an aqueous solution ofbrimonidine or a suspension of brimonidine in mineral oil or petrolatumjelly) is absorbed in or adhered to the head portion. The liquidcomposition contains about 0.001 to about 5 mg/ml brimonidine orbrimonidine and, optionally, corticosteroids (e.g., methylprednisone)CRGP receptor antigonists or anti-CGRP receptor monoclonal antibodies,adrenomedullin inhibitors, serotonin inhibitors, cathelicidininhibitors, or neuropeptides.

In another embodiment, the applicator sticks may be packaged in a rigidtray made of molded synthetic plastic material, the tray comprising atray-forming body with a depression so that external compression forceson the applicator heads will not squeeze the liquid therefrom. Inanother embodiment, the rigid tray may have severable sections, eachcontaining one or more applicator sticks for easy removal of the desirednumber of applicators. A flexible, gas impermeable cover sheet that isreleasably but sealingly secured over the rigid tray(s) provides agas-tight seal for the tray or tray sections involved and completes thesealing of the well-forming depression. The cover preferably comprisesan upper layer made of a paper-like material and upon the outer face ofwhich is printed information identifying the type of applicator involvedand the medicinal material applied to the head portion thereof, and atrademark or logo identifying the manufacturer of the product.

In another embodiment, the package includes a tray-like body providing adepressed well and support ledge-forming portions shaped and arranged tocooperate respectively with the head and handle the applicator sticks soas to locate the head portions thereof below the handles and in headprotecting wells, and with the portions of the handles to be graspedinclining and/or spaced upwardly so as to be out of contact with anybottom surfaces of the tray. In such case, the swabs or applicatorsticks can be more conveniently grasped. The package is completed by aflexible, gas-impervious, cover sheet as described above.

The applicator of the present invention has its most importantapplications in two basically different forms of packages. In one form,each of the swabs or applicator sticks is sealed within a separablesection of the tray-like body of the package. In the other form, thetray-like body of the package is a non-separable body and supports anumber of swabs or applicator sticks either in a single compartment,whereupon removal of a single non-severable cover sheet therefrom allswabs or applicator sticks are simultaneously visible and preferablygraspable at one time, or in separate compartments where each can beexposed separately as a severable portion of an overlying cover sheet ispeeled from the tops of the package. The applicator head portion of theapplicator sticks of the invention contain a controlled amount of aliquid composition comprising an alpha 2 adrenergic agonist.

In another aspect, the invention relates to methods of treating asubject or human patient suffering from an eye disorder by administeringto the to the eye of the human patient an ophthalmologicalpharmaceutical formulation having a therapeutically effective amount ofone more alpha 2 adrenergic agonists or a pharmaceutically acceptablesalts thereof. The alpha-2-adrenergic agonist or mixtures thereof ispresent in an amount effective to provide a desired therapeutic benefitto a patient suffering from an eye disorder to whom the composition isadministered. The therapeutically effective amount should be sufficientto realize relief from the eye disorder after the treatment.

In one embodiment, the alpha-2-adrenergic agonist is or includesbrimonidine or a pharmaceutically acceptable salt thereof. The eye of asubject or human patient can be the entire eye structure or a tissue orgland in or around the eye such as the ocular tissue, eyelids, margin ofthe eyelid of the subject, ocular surface, Meibomian gland and orlacrimal gland of the human patient. The ophthalmological pharmaceuticalformulation is topically administrable and/or is administered in, on oraround the eye. In an embodiment of the invention, the eye disorder isdry eye syndrome or MGD. The dry eye syndrome may be aqueoustear-deficient dry eye (ADDE) or evaporative dry eye (EDE) or consistsof both ADDE and EDE (mixed mechanism dry eye). In one preferredembodiment, MGD is treated according to this invention by applying atherapeutically effective amount an alpha 2 adrenergic agonist directlyto the margin of the subject's eyelid using an applicator as describedherein. The liquid composition is applied on the skin of the lower andupper eyelid margins at the base of the eyelashes using sterile singleuse applicators. For applying on lower eyelid margin, pull the eyeliddown and apply. For applying on upper eyelid margin close the eyelidsand apply.

The actual dose of the active compounds of the present invention dependson the specific compound, and on the condition to be treated; theselection of the appropriate dose is well within the knowledge of theskilled artisan.

Additional objects, advantages, and novel features of this inventionwill become apparent to those skilled in the art upon examination of thefollowing examples thereof, which are not intended to be limiting. Inthe Examples, procedures that are constructively reduced to practice aredescribed in the present tense, and procedures that have been carriedout in the laboratory are set forth in the past tense.

EXAMPLES

The following working examples further illustrate the present invention.The examples below are carried out using standard clinical proceduresand techniques that are well known and routine to those of skill in theart, except where otherwise described in detail. The working examplesare offered by way of illustration and not by way of limitation.

Example 1: Treatment of Mixed Dry Eye Disease (Severe Tear DeficiencyMeibomian Gland Dysfunction (MGD))

A patient with severe mixed dry eye disease (severe tear deficiencyMeibomian gland dysfunction (MGD) was treated with brimonidine 0.15%aqueous solution twice a day to the eyelash and eyelid margin area ofeach eye. Presence of extensive conjunctival and eyelid margin rednesswere noted before applying brimonidine. A significant reduction inconjunctival and eyelid margin redness was noted 15 minutes afterbrimonidine application (photographs of the patient's eyes taken beforeand after treatment with brimonidine not shown). The patient reportedthat symptoms of ocular discomfort reduced after applying brimonidine.

Example 2: Treatment of Ocular GVHD Patients with Meibomian GlandDysfunction

This working example is provided to demonstrate that the use ofbrimonidine tartrate ophthalmic solution) (ALPHAGAN® P) 0.15% improvescomfort (provides relief) and reduces Meibomian gland dysfunction (MGD)in patients with chronic ocular Graft-Versus-Host-Disease (oGVHD).

A total of 18 patients with chronic ocular GVHD (eyes n=36) were studiedusing subjective end points. All patients had eye lid margintelangiectasia, eye lid margin excoriation, keratinization and poor orno expression of Meibomian glad secretion upon digital pressure. Onedrop of brimonidine solution was instilled twice a day on the ocularsurface of each eye and the patients were instructed to immediatelygently close the eye lids. Eye drop solution that escaped over the eyelid/eye lashes was spread on the eye lid margin using their fingertip.Patients were followed for 6 months or more. On follow up visitspatients were asked to assess their overall change in comfort and MGDsigns (redness of eye lid margin) from baseline. This Subjective GlobalAssessment (SGA) was performed as follows: Question (to patient):compared to before using brimonidine and now, how is your overall ocularcomfort and eye lid margin/ocular redness? The responses werecategorized on a five point scale as follows: Much worse, Worse, Aboutthe same, Improved and Much improved. At each visit, the physician(Sandeep Jain, MD) used his clinical evaluation (all signs and symptomstaken together) to provide a global assessment of the patients' changein MGD symptoms and signs. The Clinical Global Impression (CGI)responses were categorized on a seven point scale as follows: Markedworsening, Moderate worsening, Minimal worsening, Unchanged, Minimalimprovement, Moderate improvement and Marked improvement.

Relevance of CGI (SGA) score to clinical end point in mean OSDI is theprimary efficacy endpoint. In the Restasis Review of Efficacy and Safetyvs Tears in the Relief of Dry Eye (RESTORE) study, minimal clinicallyimportant difference (MCID) was determined for the Ocular SurfaceDisease Index (a 12-item patient-reported outcome questionnaire designedto quantify ocular disability due to dry eye disease) (PMID: 20065224).A clinician global impression (CGI) and a subject global assessment(SGA) served as anchors to estimate the MCD for the overall OSDI score(range, 0-100). The overall OSDI score defined the ocular surface asnormal (0-12 points) or as having mild (13-22 points), moderate (23-32points), or severe (33-100 points) disease. The CGI and SGA correlatedwith the OSDI score change for all OSDI categories.

The mean (±SD) SGA was 4.4±0.69 suggesting that most patients reportedsubjective benefit from Brimonidine use. No patients reported worseningof symptoms or signs. Of the tested patients, 11% patients (n=2) did notreport any change. 33% patients (n=6) reported improvement where as 55%patients (n=10) reported much improvement. The mean (±SD) CGI was6.2±0.88 suggesting that most patients had clinical benefit fromBrimonidine use. No patients had clinically worsened. 83% patients(n=15) had moderate to marked improvements in CGI. The eye drops wereeasily tolerated. The subjective beneficial effects reported were:reduced redness of eye lid margin and ocular surface, less need forconcomitant artificial tear eye drops, less eye lid discomfort andeasier opening of eyes in the morning. The clinical beneficial effectnoted were: reduced eye lid margin telangiectasia, reduced eye lidmargin excoriation and improved expression of Meibomian glad secretionupon digital pressure.

Thus, it has been demonstrated that the use of brimonidine to treatMeibomian gland dysfunction in ocular GVHD patients led to a beneficialeffect in approximately 90% of the patients tested without significantside effects.

Example 3: Treatment of Patient(s) Diagnosed as Suffering from SjogrenDry Eye Syndrome

The patient was a 52-year-old female with documented history ofSjogren's syndrome. The prior treatment history was that the patientreceived steroid eye drops, bandage contact lens, systemic doxycycline,evoxac and extensive lubrication of the ocular surface. The patient hadlittle improvement in signs and symptoms even after such an aggressivetreatment. After a period of time, the patient underwent pre-treatmentexamination followed by treatment according to the invention herein. Thepatient showed severe symptoms of ocular discomfort, severe teardeficiency (Schirmer I of 4 mm in the right eye and 3 mm in the lefteye), extensive ocular surface disease with 3+ corneal rose bengalstaining in both eyes and presence of Meibomian gland dysfunction (MGD)in both eyes. The patient was treated with brimonidine 0.15% twice a dayin both eyes. The patient was instructed to instil brimonidine on theeye surface and close the eye lids to spread excess drug onto eye lidmargins of both eyes. The patient has reported improvement in symptomsand redness with brimonidine use.

Example 4: Treatment of Patient(s) Diagnosed as Suffering fromNon-Sjogren Dry Eye Syndrome (MGD not Due to Ocular GVHD)

The patient treated was a 59-year-old female with persistent complainsof redness, irritation, burning and stinging in both eyes. Pre-treatmentexamination revealed normal aqueous tear production (Schirmer I of 16 mmin the right eye and 13 in the left eye). Significant amount of lidmargin telangiectasia was present along with Meibomian gland dropout andpoor flow of oil on digital pressure. Patient did not have anyautoimmune disorder. A diagnosis of Meibomian gland dysfunction (MGD)was made. The patient had little improvement in signs and symptomsfollowing aggressive treatment that included steroid eye drops andsystemic doxycycline pills. To demonstrate efficacy according to theinvention herein, the patient was subject to brimonidine 0.15% twice aday. The patient applied brimonidine eye drops to both eyes and spreadthem on upper and lower lids of both eyes. On the most recent follow upthe patient reported reduction in symptoms of dryness and burning andreduction in redness of both eyes with continued use of brimonidine. Noside effects were reported and the drops were tolerated well. Patientwishes to continue using brimonidine.

Example 5: Treatment of Patients Diagnosed as Suffering from EvaporativeDry Eye (EDE)—Attributable to LASIK Refractive Surgery

The patient treated was a 55-year-old female with severe symptoms ofocular discomfort. The patient had undergone LASIK refractive surgery inboth eyes. The prior treatment history was that the patient was ondoxycycline pills, warm compresses, erythromycin ointment andintermittently on steroid eye drops. The patient had little improvementin signs and symptoms. The examination of the patient, prior to thetreatment according to the invention herein, revealed borderline teardeficiency (Schirmer I of 10 mm in the right eye and 11 mm in the lefteye), mild corneal fluorescein staining and reduced corneal sensation inboth eyes. Significant eye lid margin telangiectasia and Meibomian glanddysfunction (MGD) was seen in both eyes. To demonstrate efficacyaccording to the invention herein, brimonidine eye drops 0.15% wereadministered in both eyes. The patient instilled the eye drops on thesurface of the eye and spread the excess eye drops to both eye lidmargins. On the most recent follow up, the patient reported thatsymptoms improved 90% since starting brimonidine and wishes to continueusing these eye drops.

The foregoing discussion of the invention has been presented forpurposes of illustration and description. The foregoing is not intendedto limit the invention to the form or forms disclosed herein. Althoughthe description of the invention has included description of one or moreembodiments and certain variations and modifications, other variationsand modifications are within the scope of the invention, e.g., as may bewithin the skill and knowledge of those in the art, after understandingthe present disclosure. It is intended to obtain rights which includealternative embodiments to the extent permitted, including alternate,interchangeable and/or equivalent structures, functions, ranges or stepsto those claimed, whether or not such alternate, interchangeable and/orequivalent structures, functions, ranges or steps are disclosed herein,and without intending to publicly dedicate any patentable subjectmatter. All references cited herein are incorporated by reference intheir entirety.

What is claimed is:
 1. A preservative free aqueous ophthalmic solutioncomprising: (a) an alpha 2 adrenergic agonist, a pharmaceuticallyacceptable salt thereof, or a combination thereof; (b) a nanoemulsion ofoil; (c) a pharmaceutically acceptable excipient; and (d) water.
 2. Thepreservative free aqueous ophthalmic solution of claim 1, wherein saidalpha 2 adrenergic agonist has a higher alpha 2A agonist activitycompared to alpha 2B agonist activity.
 3. The preservative free aqueousophthalmic solution of claim 1, wherein said pharmaceutically acceptableexcipient is selected from the group consisting of: a crosslinkingagent, a surfactant, gum, a resin, a pH adjuster, a stabilizer, anantioxidant, an ultraviolet absorbent, a wetting agent, and acombination thereof.
 4. The preservative free aqueous ophthalmicsolution of claim 3, wherein said pharmaceutically acceptable excipientcomprises polysorbate 80, poloxamer, tylaxopol, carbomer, glycerin,sodium hydroxide, hydrochloric acid, or a combination thereof.
 5. Thepreservative free aqueous ophthalmic solution of claim 3, wherein saidpharmaceutically acceptable excipient comprises polysorbate 80, castoroil, carbomer, glycerin, sodium citrate, tris base, sodium hydroxide,hydrochloric acid, or a combination thereof.
 6. The preservative freeaqueous ophthalmic solution of claim 1, wherein the droplet size of saidnanoemulsion is less than 200 nm.
 7. The preservative free aqueousophthalmic solution of claim 1, wherein said nanoemulsion comprises atleast a portion of said alpha 2 adrenergic agonist.
 8. The preservativefree aqueous ophthalmic solution of claim 1, wherein said nanoemulsionof oil comprises one or more oils selected from the group consisting of:castor, olive, soy, corn, mineral, cottonseed, safflower and sesame. 9.The preservative free aqueous ophthalmic solution of claim 1, whereinsaid alpha 2 adrenergic agonist comprises brimonidine, apharmaceutically acceptable salt thereof, or a combination thereof. 10.A method of treating a patient suffering from a dry eye syndromecomprising administering to an eye of the patient in need of such atreatment a preservative free ophthalmic formulation comprisingnanoemulsion of oil, and a therapeutically effective amount an alpha 2adrenergic agonist, a pharmaceutically acceptable salt thereof, or acombination thereof.
 11. The method of claim 10, wherein said alpha 2adrenergic agonist has a higher alpha 2A agonist activity compared toalpha 2B agonist activity.
 12. The method of claim 10, wherein the alpha2 adrenergic agonist comprises brimonidine, a pharmaceuticallyacceptable salt thereof, or a combination thereof.
 13. The method ofclaim 10, wherein the dry eye syndrome comprises Meibomian glanddysfunction (MGD).
 14. The method of claim 10, wherein said formulationis administered directly to the margin of the patient's eyelid.
 15. Themethod of claim 10, wherein the dry eye syndrome is aqueoustear-deficient dry eye (ADDE).
 16. The method of claim 15, wherein theADDE is Sjogren dry eye syndrome, ocular Graft-Versus-Host-Disease(oGVHD) or non-Sjogren dry eye syndrome.
 17. The method of claim 15,wherein the ADDE is oGVHD.
 18. The method of claim 10, wherein the dryeye syndrome is evaporative dry eye (EDE).
 19. The method of claim 10,wherein the dry eye syndrome is mixed mechanism dry eye consisting ofaqueous tear-deficient dry eye (ADDE) and evaporative dry eye (EDE). 20.The method of claim 10, wherein the dry eye syndrome is a complicationof LASIK refractive surgery or is attributable to one or more causesselected from the group consisting of: vitamin A deficiency, ocularsurface disorders, allergy, aging, contact lens usage and medicationusage and disorders of eyelid aperture.